The free-standing emergency room industry has launched a fierce challenge to a recent academic study examining the pricing of emergency care in Texas, not only attacking the validity of the data but allegedly striking at the professional integrity of the authors.

The preliminary findings of the study, posted on a medical journal's website in March but now removed, showed stark disparities in the prices charged for the same diagnosis depending on which type of clinic or emergency room a patient chooses. That can lead to confusion and ultimately sticker shock, the study found.

Lead author Vivian Ho of Houston said this week that Dr. Paul Kivela, president-elect of the American College of Emergency Physicians, contacted her in April to complain about some numbers in an appendix and implied she could be sued.

The emergency physicians group said in a statement that it "did not and does not support or condone any interference on study authors." The organization, headquartered near Dallas and representing 36,000 members nationwide including those in the free-standing emergency room industry, declined further comment.

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It is a rare storm in the typically staid world of academic research. At its heart is a 15-page article on price disparities in emergency care in Texas.

"They don't like the findings and they don't want them to see the light of day," said Ho, a health economist at Rice University's Baker Institute for Public Policy who led the study, which was funded by the Texas Medical Center Health Policy Institute.

She said Kivela questioned her about her affiliations with insurers. She said she interpreted the questions as a veiled accusation she was receiving some type of incentive to skew the results.

"What are you accusing me of?" she said she asked Kivela.

Ho added that in her 26 years in academia she has never felt so bullied. "I'm horrified they are saying I'm unethical," she said.

Using 16 million insurance claims provided by the state's largest insurer, Blue Cross and Blue Shield of Texas, Ho and a team of economic and health-care researchers from some of Houston's most respected institutions analyzed medical codes and found that on average a patient can be charged as much as 10 times more in a free-standing emergency room center than in the lower-priced urgent care clinic for the same diagnosis.

Both types of clinics have proliferated in recent years in Texas and across the country, offering walk-in service as a more convenient alternative to traditional hospital emergency rooms.

Reimbursement rates

The study explained that free-standing emergency centers are expensive to operate because they are more regulated than the urgent care clinics, must treat everyone regardless of ability to pay, and offer a higher level of treatment than their lower-cost cousins.

But it also concluded that people can be confused by the similar appearance and placement in retail centers, potentially leading to hundreds if not thousands of dollars worth of surprise medical bills if a patient with minor needs walks in the wrong door.

The research was submitted to and accepted by the Annals of Emergency Medicine for publication. A preliminary version appeared on the medical journal's website in March, and Rice University publicized it in a news release on March 23. The findings were picked up by media outlets across the state, including the Houston Chronicle.

Six days later, a public relations firm for the Texas Association of Freestanding Emergency Centers contacted Texas reporters and said one of the study's authors, Dr. Cedric Dark, had disavowed the study. Dark responded that wasn't true. In a Chronicle interview at the time, he said he thought it was problematic to compare the types of centers because of the different levels of available care but that he stood by the overall findings.

The public relations firm backed off the assertion.

Dark said he did not want to discuss the latest fallout.

Ho said Kivela called her April 10 about the potential conflicts of interest and sent her an email last week with further complaints about numbers in the study.

In addition to Ho, the other authors came from Baylor College of Medicine, UTHealth's School of Public Health, the Michael E. DeBakey VA Medical Center and Blue Cross and Blue Shield.

Meanwhile, drama was building on another front.

Several emergency-room physicians began lodging complaints with the medical journal, saying the data were incorrect, Dr. Michael Callaham, professor emeritus of emergency medicine at the University of California-San Francisco and editor-in-chief of the publication, said in an email.

The journal is the official publication of the American College of Emergency Physicians, but Callaham said he demands editorial independence.

The complaints centered on data concerning reimbursement rates paid to doctors, Callaham said. Ho acknowledged a transcription error in an appendix, not the body of the study, as the reimbursement figures were transferred from one format to another. She said the information was corrected.

Followed protocol

Critics now say the entire study should be disregarded because of that error.

Callaham said in an email that he found the complaints serious enough to remove the paper from its website for additional review. The print version was scheduled for June but has now been put off until after the review, he said. A note on the website now says the online article "has been temporarily removed."

"A replacement will appear as soon as possible in which the reason for the removal of the article will be specified or the article will be reinstated," the note says.

The removal of the article was first reported by HealthDataBuzz. Callaham said he was not pressured by ACEP but made the decision based on protocol when ethical questions arise.

One who complained is Dr. Carrie De Moor, CEO of Frisco-based Code 3 Emergency Partners and president of the ACEP's free-standing emergency centers section. She sees something much darker than a typo, accusing Blue Cross and Blue Shield of deliberately manipulating and providing false data as part of a "smear campaign against emergency medicine doctors" to keep reimbursement rates low.

She did not accuse the authors of collusion, however.

The majority of Texas' independent free-standing emergency rooms are physician-owned, but De Moor said her complaints had nothing to do with the financial stakes of the centers.

"I'm more concerned about my patients," she said, accusing insurers of confusing them by "trying to get them to go to urgent care instead of an emergency room."

Blue Cross and Blue Shield pushed back hard Wednesday against the allegations. "We stand by the accuracy of the data used in the study," the insurer said in an email statement, adding it "firmly supports the work done by researchers led by Vivian Ho."

John Budd, who studies academic research as professor emeritus of the University of Missouri's School of Information Science and Learning Technologies, said he was surprised at the toxicity surrounding the incident. Attacking the integrity of a study's author and threatening legal action is "extremely rare," he said.

"I'm not worried for my reputation," Ho said. She said she has found an outpouring of support from colleagues and other academics. Still she finds it all rather baffling. "All we were trying to do was lower health-care costs."

Jenny Deam came to the Houston Chronicle in March 2015 from Denver, trading thin air for thick. She writes about the business of health care. Prior to joining the Chronicle she was a special correspondent for the Los Angeles Times based in Denver. She has been a reporter for the Denver Post, the Tampa Bay Times, the Kansas City Star and has written for regional and national magazines. She is a graduate of Washburn University